They happen nearly everywhere — in hospitals big and small, on units frenzied and quiet. Medication errors: the most common medical mistakes identified by the Institute of Medicine in a landmark 1999 study. Each year, as many as 7,000 patient deaths in the US can be attributed to medication errors, the study found.¹

Nurses fear the very thought of committing serious medication errors. Because we deal with patients directly, ultimately the responsibility for ensuring that errors do not occur falls to us. It’s a heavy responsibility, but one we don’t have to shoulder alone.

“The fact is administration is only one part of the medication-use process. We need to think of the process as a continuum,” says Michael R. Cohen, RPh, DSc, president of the Institute for Safe Medication Practices (ISMP), a nonprofit organization dedicated to the promotion of medication safety practices in hospitals and healthcare systems.

Errors can originate in any part of that continuum — prescribing, transcribing, dispensing, administering, or monitoring.

“Medication use is a complex, multidisciplinary process, and we can’t fix just one part of the chain,” says Cohen. “Instead, if we use root-cause analysis, we can identify the real problems within the system.”

Cohen believes that taking a team-, systems-based approach, rather than focusing on blame, is the key to reducing medication errors. Through enhanced collaboration, nurses, pharmacists, and physicians can work together to reduce serious errors.

Stopping Errors Before They Begin

Hospital pharmacists perform pharmacy interventions on a daily basis, and they offer unique expertise in detecting potential errors.

“Having a pharmacist on the unit cuts down on errors,” says Cohen. In fact, a recent study published in The Journal of the American Medical Association indicates that adding pharmacists to patient rounds reduced med errors by 66%.²

“When the pharmacist is on the unit, he or she can review the side effects, interactions, and drug implications with the nurse and the physician immediately,” intercepting potential errors before medication administration takes place, Cohen says.

Linda Burnes Bolton, RN, DrPH, FAAN, vice president and chief nursing officer, Cedars-Sinai Health System and Research Institute, Los Angeles, views pharmacists as key operatives in medication safety.

“We have a dedicated pharmacist on all patient units, including the ED,” says Bolton. “Our nurses, pharmacists, and physicians work in tandem.”

Before a drug is administered, Bolton says, the unit pharmacist reviews the patient profile and gives the nurse an extensive review of the medication. Some profiles, like those of transplant patients, are complex. “We especially look at high-risk drug issues — those medications that have quick reactions and are hard to reverse,” she says.

The pharmacist’s input is extremely valuable when it comes to these high-alert drugs — those that if improperly dosed or delivered have a high risk of serious injury or death. Experts estimate that 20% of medications fall into this category.³ Although there’s no indication drug errors occur more frequently with high-alert drugs, the results of these errors can be life-threatening.

At Cedars-Sinai, double-checking identified high-alert drugs before administering them is an established part of the hospital’s medication safety initiative.

“The nurses can double-check with another nurse or the pharmacist,” Bolton says. “Pharmacists help us stay on top of medication safety.”

Learning from Others

When errors happen internally, it’s tempting to find fault rather than step back, view them objectively, and search for system weaknesses.

“Don’t wait for an accident to happen,” says Hedy Cohen, RN, BS, vice president of ISMP. “Instead, be proactive by reviewing errors that other facilities report. The likelihood is eventually you will make the same type of mistakes.”

Typically, new drugs are approved through hospitals’ multidisciplinary pharmacy and therapeutics (P&T) committees. Safety factors rank high in consideration of their addition to the hospital formularies.

“Part of what pharmacists do is look at whether a drug has a complicated method of use or if the drug looks or sounds like another, resulting in name confusion, or it has many side effects,” says Michael Cohen.

After the P&T meeting, pharmacists follow up with newsletters explaining the drug’s use, dosage, side effects, and other pertinent information.

Adding the Sixth Right

The concept of the five rights of administration — the right patient, the right drug, the right dose, the right time, and the right route — still holds great importance in today’s complex care. But “the five rights aren’t necessarily enough,” says Hedy Cohen. “Nurses should make sure they add the sixth right: diagnosis.”

She offers an example: “Consider a patient with a new order for insulin. If all the other rights are there, but the patient isn’t diabetic, implementing the sixth right will avoid an error.” She recommends that nurses avoid the mindset of medication “passing.”

“This mindset describes a passive task,” she says, “while administration involves a cognitive thought process.” Along with diagnosis, she cautions nurses to be cognizant of any required monitoring or connected lab work.

Embracing Technology

Changing systems to prevent medication errors can be stressful and, initially, may seem to take more time.

“Be open and recognize the positives of technology,” advises Michael Cohen. “Take it slow, realize it takes time to get it running smoothly.” Technology will never replace skilled professionals, but connecting the two adds another dimension to medication safety, he says.

“Technology has a very important role, and its use can help ensure you keep important patient information,” says Bolton. When patients are admitted to Cedars-Sinai, she says, their medical profiles are entered throughout the system and can be sourced not only for later admissions, but also within the facility’s outpatient clinics.

Many technological tools help prevent errors during prescribing and administration — close to the point of care. Some of the weapons that can be added to nurses’ medication safety arsenal include —

• “Smart” pump: Prevents overdosing, especially valuable when administering high-alert medication
• Computerized physician order entry: Has a built-in alert system for dosages, contraindications, and interactions; also decreases transcribing and dispensing errors
• Bar coding: Helps ensure the right patient receives the right medication
• Linked automated systems: Provides medical information that can be accessed by all appropriate users

Although the use of this technology is not yet widespread, it is growing. It’s costly and requires intensive inservice for staff. It’s important, however, that all those involved in the medication-use process have input in selecting and evaluating what will work best within their care setting.

Collaboration Will Continue

Before nurses can actively address the problems of medication errors, they must determine where their current system may be faulty.

“That’s the way you improve,” says Bolton. Cedars-Sinai established a Medication Safety Collaborative, an interdisciplinary committee with nurses, pharmacists, physicians, and administrators who work toward ensuring medication safety.

“We used the self-assessment tool developed by ISMP in our search for safe medical practice,” Bolton says. The tool is available through the ISMP website at www.ismp.org.

The growing shortage of nurses and pharmacists, however, only adds to the complexity of improving medication safety. Hedy Cohen suggests ways that pharmacists and nurses can share the burden of safe medication administration. Pharmacists, for example, can help determine which medications can be given differently, perhaps spreading the administration of drugs evenly across nursing shifts, she says.
Although there’s no easy, one-size-fits-all solution to medication errors, there’s also no doubt a team approach can improve the safety of medication-delivery systems. Working together, pharmacists and nurses can mount a powerful force in reducing errors.